SPINAL INJURY

A spinal cord injury — damage to any part of the spinal cord or

nerves at the end of the spinal canal (cauda equina) — often causes
permanent changes in strength, sensation and other body functions below
the site of the injury.

CAUSES

The most common causes of spinal cord injuries in the United States are:

 Motor vehicle accidents. Auto and motorcycle accidents are the leading cause of spinal
cord injuries, accounting for almost half of new spinal cord injuries each year.

 Falls. A spinal cord injury after age 65 is most often caused by a fall.

 Acts of violence. About 12% of spinal cord injuries result from violent encounters, usually
from gunshot wounds. Knife wounds also are common.

 Sports and recreation injuries. Athletic activities, such as impact sports and diving in
shallow water, cause about 10% of spinal cord injuries.

 Diseases. Cancer, arthritis, osteoporosis and inflammation of the spinal cord also can cause
spinal cord injuries.

RISK FACTORS

Although a spinal cord injury is usually the result of an accident and can happen to anyone,
certain factors can predispose you to being at higher risk of having a spinal cord injury,
including:

 Being male. Spinal cord injuries affect a disproportionate number of men. In fact, females
account for only about 20% of traumatic spinal cord injuries in the United States.
  Being between the ages of 16 and 30. More than half of spinal cord injuries occur in
people in this age range.

 Being 65 and older. Another spike in spinal cord injuries occurs at age 65. Falls cause
most injuries in older adults.

 Alcohol use. Alcohol use is involved in about 25 % of traumatic spinal cord injuries.

 Engaging in risky behavior. Diving into too-shallow water or playing sports without

wearing the proper safety gear or taking proper precautions can lead to spinal cord injuries.
Motor vehicle crashes are the leading cause of spinal cord injuries for people under 65.

 Having certain diseases. A relatively minor injury can cause a spinal cord injury if you
have another disorder that affects your joints or bones, such as osteoporosis.

SIGNS AND SYMPTOMS

Signs and symptoms of a spinal cord injury after an accident include:

 Extreme back pain or pressure in your neck, head or back

 Weakness, incoordination or paralysis in any part of your body

 Numbness, tingling or loss of sensation in your hands, fingers, feet or toes

 Loss of bladder or bowel control

 Difficulty with balance and walking

 Impaired breathing after injury

 An oddly positioned or twisted neck or back

PATHOPHYSIOLOGY

DIAGNOSIS/LABORATORY TESTS

In the emergency room, a doctor may be able to rule out a spinal cord injury by examination,
testing for sensory function and movement, and by asking some questions about the accident.

But if the injured person complains of neck pain, isn't fully awake, or has obvious signs of
weakness or neurological injury, emergency diagnostic tests may be needed.
These tests can include:

 X-rays. X-rays can reveal vertebral (spinal column) problems, tumors, fractures or

degenerative changes in the spine.

 CT scan. A CT scan can provide a clearer image of abnormalities seen on X-ray. This scan
uses computers to form a series of cross-sectional images that can define bone, disk and
other problems.

 MRI. MRI uses a strong magnetic field and radio waves to produce computer-generated
images. This test is helpful for looking at the spinal cord and identifying herniated disks,
blood clots or other masses that might compress the spinal cord.

A few days after injury, when some of the swelling might have subsided, your doctor will
conduct a more comprehensive neurological exam to determine the level and completeness of
your injury. This involves testing your muscle strength and your ability to sense light touch and
pinprick sensations.

MEDICAL MANAGEMENT

Initial assessment
See major trauma-primary survey guideline (link) and cervical spine injury guideline (link) for
initial assessment

 Be aware the loss of thoracic sympathetic innervation (T1-T5) may inhibit tachycardia
and vasoconstriction as signs of hypovolaemia. Thus haemorraghic injuries may not be
indicated by the usual signs.

Referrals

 Neurosurgical, orthopaedics & trauma service should be notified prior to or on admission

to the Emergency department
 Rehabilitation service to be notified within 24 hours of admission

Admission location

 These patients will usually require admission to PICU (Rosella)

 If not requiring PICU admission, then this will usually be Cockatoo (Neurosurgical ward)
unless multiple abdominal injuries are present, in which case the child will be admitted to
Platypus (General surgical ward)
Spinal immobilisation
See cervical spine injury guideline (link)

 Initial care - immobilisation:

 Immobilize the entire spine of any patient with known or potential SCI
 Immobilize neck with a hard collar. See guideline for cervical spine assessment
(link)
 Use log roll with adequate personnel to turn patient while maintaining spine
alignment
 For children < 8 years of age use an airway pad to promote neutral cervical spine
position (link to resource)
 Remove from spinal board on arrival in ED or as soon as resuscitation allows 
 Maintain neck in neutral position by use of a hard collar, but change to two-piece
collar for comfort and avoidance of complications (e.g. pressure area, venous
obstruction, aspiration) within 6 hours of admission. 
 Early surgery:
 Surgery may be required in the situation of a reversible compression injury, or
deteriorating neurology with a spinal injury amenable to some form of reduction
and or fixation. 
 Halo & Orthotic devices:
 Some patients may have Halo devices applied by surgeons, or a brace made by
orthotics to maintain correct alignment of the spine. These devices are fixed to the
child’s chest.
 Ensure you know how to open devices to perform chest compressions in the event
of a cardiac arrest, and that spinal immobilisation is maintained manually
throughout any resuscitation 
 Move patient using slide sheets or pat slide with adequate number of personnel to
maintain spinal alignment 
 No pharmacological agent has been proven to limit damage and optimize recovery of
function. If steroids have already been given, cease them when resuscitation completed.
Aim for normal perfusion pressure and oxygenation of SC. 
 Once the extent and stability of the injury has been determined a documented plan should
be formulated to ensure immobilisation and stabilisation. 

Imaging

 Multiple levels of injury in the spine are common. In the under 8 age group especially,
there is a high proportion of missed craniocervical injuries with/ without associated
cranial nerve involvement. 

 plain film imaging of the entire cervical, thoracic and lumbar spines
 Further early imaging will at least involve an urgent MRI of the entire spine
looking for remediable lesions
 CT scan may be used to further identify the extent of bony injury
MEDICATIONS

Medications might be used to manage some of the effects of spinal cord injury. These include
medications to control pain and muscle spasticity, as well as medications that can improve
bladder control, bowel control and sexual functioning.

New technologies

Inventive medical devices can help people with a spinal cord injury become more independent
and more mobile. These include:

 Modern wheelchairs. Improved, lighter weight wheelchairs are making people with spinal
cord injuries more mobile and more comfortable. Some people need an electric wheelchair.
Some wheelchairs can even climb stairs, travel over rough ground and elevate a user to
reach high places without help.

 Computer adaptations. For someone who has limited hand function, computers can be
difficult to operate. Computer adaptations range from simple to complex, such as key
guards and voice recognition.

 Electronic aids to daily living. Essentially any device that uses electricity can be
controlled with an electronic aid to daily living. Devices can be turned on or off by switch
or voice-controlled and computer-based remotes.

 Electrical stimulation devices. Often called functional electrical stimulation systems,

these sophisticated devices use electrical stimulators to control arm and leg muscles to
allow people with spinal cord injuries to stand, walk, reach and grip.

NURSING INTERVENTION
 Note client’s level of injury when assessing respiratory function. Note presence or
absence of spontaneous effort and quality of respiration. (e.g. labored, using accessory
muscles)
- Injuries at C5 can result in variable loss of respiratory function,
depending on the phrenic nerve involvement and diaphragmatic
function but generally cause decreased vital capacity and
inspiratory effort.
  Auscultate breath sounds. Note areas of absent or decreased breath
sounds or development of adventitious sounds.
- Hypoventilation is common and leads to accumulation of secretions,
atelectasis and pneumonia.
 Maintain client airway: keep head in neutral position, elevate head of bed
slightly if tolerated, and use airway adjunct as indicated.
- Clients with high cervical injury and impaired cough reflex needs
assistance in preventing aspiration/maintaining patent airway.
 Assist client in taking control of respirations as indicated. Instruct and
encourage deep breathing focusing attention on steps of breathing.
- Breathing may no longer be a totally involuntary activity but require
conscious effort, depending on level of injury/involvement of
respiratory muscles.

COMPLICATIONS

At first, changes in the way your body functions can be overwhelming. However, your
rehabilitation team will help you develop tools to address the changes caused by the spinal cord
injury, in addition to recommending equipment and resources to promote quality of life and
independence. Areas often affected include:

 Bladder control. Your bladder will continue to store urine from your kidneys. However,
your brain might not control your bladder as well because the message carrier (the spinal
cord) has been injured.

The changes in bladder control increase your risk of urinary tract infections. The changes
may also cause kidney infections and kidney or bladder stones. During rehabilitation, you'll
learn ways to help empty your bladder.

 Bowel control. Although your stomach and intestines work much like they did before your
injury, control of your bowel movements is often altered. A high-fiber diet might help
regulate your bowels, and you'll learn ways to help control your bowel during
rehabilitation.

 Pressure injuries. Below the neurological level of your injury, you might have lost some
or all skin sensations. Therefore, your skin can't send a message to your brain when it's
injured by certain things such as prolonged pressure.
 This can make you more susceptible to pressure sores, but changing positions frequently —
with help, if needed — can help prevent these sores. You'll learn proper skin care during
rehabilitation, which can help you avoid these problems.

 Circulatory control. A spinal cord injury can cause circulatory problems ranging from low
blood pressure when you rise (orthostatic hypotension) to swelling of your extremities.
These circulation changes can also increase your risk of developing blood clots, such as
deep vein thrombosis or a pulmonary embolus.

Another problem with circulatory control is a potentially life-threatening rise in blood

pressure (autonomic dysreflexia). Your rehabilitation team will teach you how to address
these problems if they affect you.

 Respiratory system. Your injury might make it more difficult to breathe and cough if your
abdominal and chest muscles are affected.

Your neurological level of injury will determine what kind of breathing problems you have.
If you have a cervical and thoracic spinal cord injury, you might have an increased risk of
pneumonia or other lung problems. Medications and therapy can help prevent and treat
these problems.

 Bone density. After spinal cord injury, there's an increased risk of osteoporosis and
fractures below the level of injury.

 Muscle tone. Some people with spinal cord injuries have one of two types of muscle tone
problems: uncontrolled tightening or motion in the muscles (spasticity) or soft and limp
muscles lacking muscle tone (flaccidity).

 Fitness and wellness. Weight loss and muscle atrophy are common soon after a spinal cord
injury. Limited mobility can lead to a more sedentary lifestyle, placing you at risk of
obesity, cardiovascular disease and diabetes.

A dietitian can help you eat a nutritious diet to sustain an adequate weight. Physical and
occupational therapists can help you develop a fitness and exercise program.

 Sexual health. Men might notice changes in erection and ejaculation; women might notice
changes in lubrication after a spinal cord injury. Physicians specializing in urology or
fertility can offer options for sexual functioning and fertility.
 Pain. Some people have pain, such as muscle or joint pain, from overuse of particular
muscle groups. Nerve pain can occur after a spinal cord injury, especially in someone with
an incomplete injury.

 Depression. Coping with the changes a spinal cord injury brings and living with pain
causes depression in some people.